We would appreciate your feedback! Name * First Name Last Name Provider * Phone Number * (###) ### #### Email * Date of Service or Call What is the date of service or call to which this survey applies? MM DD YYYY How satisfied are you with the following? For any answers marked Very Dissatisfied or Extremely Dissatisfied – we urge you to include additional comments at the end of this survey to better assist in identifying the issue. Please be specific for each answer on your survey. Example: If you are not satisfied with the ease in obtaining follow-up information please let us know specifically what item you are referring to. This can help us identify if we are having issues with a specific specialty office or policy we have in place that may improve your experience. Please keep in mind our existing policies when answering this survey. Appointments: 1. Ease of making appointments for checkups (physical exams, well visits, routine follow-up appointments)? * 1 - Extremely Dissatisfied 2 - Very Dissatisfied 3 - Satisfied 4 - Very Satisfied 5 - Extremely Satisfied 2. Ease of making appointments for sickness? * 1 - Extremely Dissatisfied 2 - Very Dissatisfied 3 - Satisfied 4 - Very Satisfied 5 - Extremely Satisfied 3. Ease in contacting your doctor when our office is closed nights and weekends)? * 1 - Extremely Dissatisfied 2 - Very Dissatisfied 3 - Satisfied 4 - Very Satisfied 5 - Extremely Satisfied Location: 4. Our office's appearance? * 1 - Extremely Dissatisfied 2 - Very Dissatisfied 3 - Satisfied 4 - Very Satisfied 5 - Extremely Satisfied 5. Ease in obtaining follow-up information and care (test results, medicines, care instructions)? * 1 - Extremely Dissatisfied 2 - Very Dissatisfied 3 - Satisfied 4 - Very Satisfied 5 - Extremely Satisfied 6. The time it takes someone from our office to respond when you call the office with an urgent problem? * 1 - Extremely Dissatisfied 2 - Very Dissatisfied 3 - Satisfied 4 - Very Satisfied 5 - Extremely Satisfied Medical Care: 7. Was your telephone request handled in a timely and professional manner? * Yes No Not Applicable 8. If referred to a specialist, was the appointment set within an acceptable time? * Yes No Not Applicable 9. Were you happy with the overall medical care you received? * Yes No 10. Did you receive instructions about improving your health/condition? * Yes No Not Applicable 11. Preventative care is important! An annual doctor visit and regular appointments can help find problems before they start. Were you asked to book an appointment? * Yes, I booked an appointment. No, please call me. 12. If you answered "No" above, please leave your preferred phone number so that we may call you to schedule your next appointment. (###) ### #### Overall Satisfaction: 13. Would you recommend your doctor to your family or friends? * Yes No 14. Additional Comments/ Suggestions: * Please provide additional information for every question answered with "Very Dissatisfied " or "Extremely Dissatisfied.” Thank you for your feedback!
